Limbaugh Orthodontics – Secure Forms Host

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Patient Information (Adult)

Social Security Number

How many years at this address?*

Employer's Street Address

Number of years employed?

Name of Family Member*

Social Security Number

Employer Street Address

Employer's Work Phone

Numer of Years Employed?

Spouse's Cell Phone*

Patient Information (Child)

Name/Relationship of person accompanying patient to today's appointment*

Patient Lives With Whom?*

Names please.

Relationship To The Patient*

Parent, Step-Parent, Grand Parent, etc.

Who Has The Legal Custody Of The Patient?*

Names please.

Name of Family Member*

Mother's Information

Mother's Social Security Number

How many years at this address?*

Mother's Cell Phone*

Father's Information

Father's Social Security Number

How many years at this address?*

Father's Cell Phone*

Guardian's Information

Social Security Number

How many years at this address?*

Social Security Number

How many years at this address?*

Primary Insurance Information

Insurance Phone Number*

Employer/Group Name*

Subscriber/Employee*

Relationship To Patient*

Photo of front of Insurance Card

If using a mobile phone or tablet to complete this form, you can use this button to snap a photo of the card. Otherwise, you may upload a photo of it here.

Accepted file types: jpg, gif, png, Max. file size: 2 GB.

Photo of back of Insurance Card

If using a mobile phone or tablet to complete this form, you can use this button to snap a photo of the card. Otherwise, you may upload a photo of it here.

Accepted file types: jpg, gif, png, Max. file size: 2 GB.

Secondary Insurance Information

Insurance Phone Number*

Employer/Group Name*

Subscriber/Employee*

Relationship To Patient*

Emergency Contact Information

Nearest Relative Not Living With Patient*

Nearest Relative's Relationship To Patient*

Nearest Relative's Cell Phone*

Nearest Relative's Home Phone

Please Read:

We are passionate about our mission to give everyone a great smile. Please help us help you and your child by letting us know of any delayed development, social disabilities, ADD or ADHD, Bipolar, Autism, etc.

Date of last physical exam

Please describe the surgical operation(s) or illness(es).*

If yes, what medications is the patient taking?*

If yes, please date*

If taking medication, please specify:

Date of last cleaning? (approximate)

If the patient has had any head, neck, or jaw injuries, please describe:*

Please describe the patient's speech therapy?*

If yes, there is outstanding dental Treatment to be completed, describe:*

What other problem:*

If so, when and by whom?*

Authorization and Release

TO THE BEST OF MY KNOWLEDGE THE ABOVE QUESTIONS HAVE BEEN ACCURATELY ANSWERED AND IT IS MY RESPONSIBILITY TO INFORM THIS OFFICE OF ANY CHANGES TO THE PATIENT’S MEDICAL STATUS. I GIVE LIMBAUGH ORTHODONTICS PERMISSION TO PERFORM AN ORTHODONTIC EXAMINATION.

Print Name*

This is name of person filling out the form and providing signature.

Electronic Form

Patient Information (Adult)

Spouse Information

Patient Information (Child)

Responsible Party

Mother's Information

Father's Information

Guardian's Information

Male

Female

Primary Insurance Information

Secondary Insurance Information

Emergency Contact Information

Medical History

Dental History

Privacy Notice

Authorization and Release